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Steps to Becoming a Doctor

Undergraduate and Graduate Education

For problems big or small, you've probably visited the doctor at least once or twice in your life. Maybe you wondered how this person became a doctor in the first place. Or maybe you heard it takes a long time, but couldn't imagine why on earth it would. After all, how long can you possibly look at cadavers, or whatever it is that medical students do? Well, here's the story...

So, first things first, our aspiring doctor needs to graduate from high school. This may seem obvious – you need to finish high school to go to college, and then to medical school. And you're right, for most doctors, that's the way it goes. But it's worth talking a about in a little bit more detail.

In the United States most people who choose a career that requires an advanced degree do so after college. But, in much of the world outside of the USA, students actually decide right after high school.

In the USA a four-year college degree is know as a Bachelor of Arts or Sciences (BA/BS). Very generally speaking, this is a broad-based education covering many subjects such as English, History, Mathematics, Economics, and many others. Most students choose a major, and take many courses in that one specific area. But this is usually in the last two years, and the broader core curriculum must be completed.

To become a doctor you can study anything you like in college, and major in anything you want, as long as you complete the four (sometimes five) "pre-med" courses. Most American medical schools require that you have taken the following yearlong courses, with a lab: General Biology, General Chemistry, Organic Chemistry, and Physics. A year of Biochemistry also helps. The Medical College Admission Test (MCAT) is based on these courses.

Outside of the USA higher education follows a slightly different path. In many countries a four-year college degree doesn't exist. Students enter University for a six-year program. So, these students are deciding to become doctors directly out of high school. Such six-year programs incorporate both the pre-med courses, as well as the main medical courses. While there may be some more general courses offered, such as a foreign language, this type of education is much more specific.

As far as medicine goes, the end result is very similar. Medical students from both American and foreign programs are able to take the same licensing exams. But more about that later...

There are some medical schools in the USA that do something similar to the European programs, and combine the undergraduate Bachelor of Arts or Sciences (but more often Sciences) degree with the Doctor of Medicine degree. So, whereas usually college takes four years, and medical school takes another four years, these programs let you finish in seven years. You can become a doctor at about the age of twenty-five.

So, now our aspiring doctor has finished college, gotten good grades in the five pre-medical courses, and has taken the MCAT. What's next? Well, any number of things. Many students choose to go straight to medical school. But, people don't always do things the same way. As long as you have the basics, college and the MCAT, it doesn't matter if you join the Peace Corps, or windsurf in Aruba prior to med school. In fact, med schools seem to prefer people who...well...have some interests outside of just hitting the books.

Let's be nice to our aspiring doctor, and assume he successfully applied and got in. The whole topic of med school admissions would need it's own website!

We're in medical school, now what? Med school is based on the fairly simple idea that you have to crawl, before you can walk, before you can run down the hall in a white coat and a scalpel. Medical education is changing and becoming very computer-based and modern, so this is just a very rough outline. But even with all the newfangled methods, you still have to learn the stuff. Most people do it like this.

So, more or less, in your first two years you sit around a lot on uncomfortable chairs, in musty libraries, falling asleep on big books – kind of like you would expect school to be.

In your first year you learn all about everything the way it should be when it's healthy. So, you learn about things like anatomy and physiology, you dissect healthy cadavers, you learn more chemistry and biology, and you learn about drugs.

In your second year you learn about everything that can go wrong; you learn about diseases, and how to treat them. But you still learn this mostly from books and microscope slides.

Your third year you still have courses with boring lectures from dusty old professors, but – you also get to go to the hospital and wear a white coat! Granted, it's a short white coat that lets everyone know immediately that you are just a lowly medical student, but it's white! You split your time between the lectures, and actually seeing patients. In teaching hospitals there is usually a medical team led by a senior staff doctor called the "Attending." Below him there is a whole bunch of junior doctors and students arranged in a specific pecking order. The third year medical student is at the bottom of this heap. The third year is divided into "rotations." You spend a few weeks with each of the major specialties such as

Internal Medicine, Surgery, and so on. So, you have to start really combining and using the knowledge you gained in your first two years.

Fourth year, well...in fourth year you are almost a doctor, right? So, they really cut down on the lectures. You basically repeat the same rotations from the year before. But, now, you have more responsibility. You actually examine patients on your own. Not that you didn't do that before, but now people actually listen to you...sometimes. You are very highly supervised by junior doctors, but they expected you to be able to function independently. By the end of your fourth (and final!) year, you should be ready to do everything an Intern does.

You're a doctor! Med school is over! Congratulations! You're a doctor! And now the fun begins.

Even though you have an M.D. degree, they still won't give you a medical license. First you have to pass something called the United States Medical Licensing Exam (USMLE). This is a series of examinations called "Steps" that make sure you were actually awake during at least part of your four years in medical school.

American medical students usually take the exams after certain years of med school. But the exams can be taken after med school as well.

Step 1 takes one day of sitting in front of a computer answering questions, and tests what you learned in your first two years.

Step 2 is divided into two sections, and is usually taken toward the end of the third year, more or less.

CK, or Clinical Knowledge, also takes a day of answering questions on a computer.

CS, or Clinical Skills, is a day-long test where you impersonate a doctor who examines actors impersonating patients. These actors portray common medical problems, and you are observed and scored on how you deal with them.

Step 3 ties all of this together, and is usually taken in your Intern year – your first year of post-graduate medical training. This test takes two days. Roughly two-thirds of the test is more computer questions. One third, however, is an interactive program where, more or less, the computer acts like a patient, and you type in what you want to do. The computer then reacts like what would happen if you actually did in real life what you typed – including getting sicker, or not making it.

That's all well and good, but don't you need a license to practice medicine? Yes, but it's not that simple.

If you pass Step 1 and Step 2, you can get a restricted medical license – but only if you enter an approved residency-training program. This means that you are fully licensed to practice medicine but, when it comes down to it, you must be supervised at all times by a fully licensed physician.

Depending on the state you are in, after one to two years of such supervised training – and if you've passed your Step 3 exam – you can apply for a full, unrestricted, medical license.

At that point you are a doctor who is allowed to practice medicine and surgery fully independently. If you feel qualified – if, say, you've already practiced surgery in Denmark for 20 years – that's all the training you need.

Post-graduate Training

Post-graduate medical training is generally called "residency." This term comes from the older term "physician-in-residence," back from when junior doctors spent so much time in the hospital that they well-nigh lived there!

Residency can take anywhere from three to five years, depending on the specialty. Many physicians choose to further sub-specialize, and complete additional training, called "Fellowship," that can take up to another one to five years.

So, to become a kidney doctor – a Nephrologist – you train in Internal Medicine for three years, and then strictly in Nephrology for an additional two years. Likewise, to become a Child Psychiatrist, you train in General Psychiatry for three or four years, and then in child Psychiatry for an additional two years.

In just about all specialties you spend your first year as an "Intern." Much of this first year is spent working as a doctor in a variety of setting such as general hospital wards, emergency rooms, and outpatient clinics. The idea here is to first train you as a general doctor, with broad-based, general medical knowledge and skills. It's not until your second year that you begin to focus more exclusively on your chosen specialty.

...and that's it. You spend years in training focusing on your specialty, basically doing the same thing, treating the same kinds of patients, over and over again. The whole thing is essentially an institutionalized version of the 10,000-hour rule.

The 10,000 Hour Rule is just that. This is the idea (most often attributed to Dr. Anders Ericsson, the Conradi Eminent Scholar and Professor of Psychology at Florida State University) that it takes approximately 10,000 hours of deliberate practice to master a skill.

For instance, it would take 10 years of practicing 3 hours a day to become a master in your subject. It would take approximately 5 years of full-time employment to become proficient in your field. Simply work out how many hours you have already achieved and calculate how far you need to go. You should be aiming for 10,000 hours.

Pre-med, med school, and much of your first year of post-graduate medical training repeat over and over the basic principles of medicine. Then, you spend the next several years repeating over and over the basic knowledge and skills of your chosen specialty.

Once this is all done, you become "Board-eligible." That is, you are able to take (yet another!) test given by your specific specialty board. So, for example, surgeons take a board exam testing all the general knowledge a surgeon should know to be a surgeon. Likewise, a Nephrologist takes the board exam for General Internal Medicine, as well as Nephrology.

If you pass the test, you are then "Board-certified."

But, these tests are controversial. Usually, they make some sense right after you finish training. It's sort of "graduation," proving that you learned what you were supposed to learn during your residency training.

However, real life doesn't work that way. Medical knowledge is so vast, and is changing so rapidly, that most doctors limit their practice to certain things they enjoy or are good at. A nephrologist enjoys, and is good at, treating diseases of the kidney. To stay certified in Nephrology, the doctor must also be certified in Internal Medicine. After years of practicing just Nephrology, the Nephrologist simply isn't up to date on all the rest of Internal Medicine.

Likewise, a brain surgeon, who practices brain surgery exclusively, and is therefore very very good at it, may have last removed an appendix 15 years before, during training. But, to pass the exam, he needs to be up to date on the latest information on how to remove an appendix, or fix a broken leg.